Week 12 The pharmacological management of mental health disorders Flashcards
What are the 4 types of drugs used in MH disorders?
- Antianxiety drugs
- Antidepressants
- Antimanic drugs
- Antipsychotics
What are anxiolytics?
drugs that prevent the feeling of tension or fear
What are sedatives?
drugs that make you calm and make patients unaware of their environment
What are hypnotics?
drugs that cause sleep
What are minor tranquillizers?
produce a state of tranquility in anxious patients
What is anxiety?
Unpleasant state of mind, characterized by a sense of dread and fear
- May be based on actual anticipated experiences or past experiences
- May be exaggerated responses to imaginary negative situations
What are some common times to have anxiety that may require treatment?
- Very common preoperatively to reduce anxiety
- Diagnostic tests
- Fear of flights
What are some of the major anxiety disorders?
- Obsessive–compulsive disorder (OCD)
- Post-traumatic stress disorder (PTSD)
- Generalized anxiety disorder (GAD)
- Panic disorder (PD) with or without agoraphobia
- Agoraphobia (fear of crowds or public places)
- Social anxietydisorder(SAD)
What do most benzodiazepines end in?
- pam
prototype chlordiazepoxide
What kind of drugs are benzodiazepines?
antianxiety
What is the action of benzodiazepine?
- Act in the limbic system and the RAS
- Make GABA more effective
- Causes interference with neurons firing
- Lower doses cause anxiolytic effects
- Higher doses cause sedation and hypnosis
What are the indications for benzodiazepine?
- Anxiety disorders
- Alcohol withdrawal
- Hyperexcitability and agitation
- Preoperative relief of anxiety and tension
What are the pharmacokinetics of benzodiazepines?
- absorbed in GI tract
- peak levels achieved in 30 min to 2h
- lipid soluble and distribute well through out the body
- cross placenta
- enter breast milk
- metabolized in the liver
- excreted in the urine
What are the contraindications and cautions of benzodiazepine?
- Allergy to benzodiazepine
- Psychosis
- Acute narrow angle glaucoma
- Shock
- Coma
- Acute alcohol intoxication
- Pregnancy
What are some adverse effects of benzodiazepine?
- Sedation
- Drowsiness
- Depression
- Lethargy
- Blurred Vision
- Confusion
- Dry Mouth
- Constipation
- Nausea&Vomiting
- Hypotension
- Urinary Retention
What nursing considerations are there for patients on benzodiazepine?
Worry about driving or with elderly especially falls or general injury, or hypotension in some patients
What is the prototype of benzodiazepine?
diazepam
What is diazepam?
a benzodiazepine agent (antianxiety)
What are the drug to drug interactions of diazepam?
- Increased CNS depression when taken with ALCOHOL
- Increase in effect when taken with CIMETIDE, ORAL CONTRACEPTIVES or DISULFIRAM
- Decrease in effect if taken with THEOPHYLLINE or RANITIDINE
What health teaching is required for a patient who says “I’ve been on xanax for 3m and i want to be off my medication now, i’m better.”
- Avoid alcohol, driving, operating machinery, grapefruit and OTC medications (especially if they cause sedation (antihistamines), take with food
- As the nurse you would monitor for anxiety, etc.(ask and look)
- Cannot directly stop taking medication (long term use causes dependance so if they stop immediately they will have withdrawal symptoms; must taper dose down)
- sometimes have N&V, seizures, panic attacks, etc
What is an affective disorder?
- a person’s mood goes far beyond the normal “ups and downs”
What is depression?
-Severe and long-lasting feelings of sadness beyond what was the precipitating event
What is it called when a person’s mood goes far beyond the normal ups and downs?
affective disorder
What are the signs and symptoms of depression?
- Low Energy Level
- Sleep Disturbances
- Lack of Appetite
- Limited Libido
- Inability to perform ADL’s - Overwhelming feelings of
sadness, despair, hopelessness, and disorganization
(watch for suicidal thoughts)
What is the biogenic amine theory of depression?
Depression results from a deficiency of norepinephrine (NE), dopamine, or serotonin (5HT); which are all biogenic amines :)
- Monoamine oxidase (MAO) may break them down to be recycled or restored in the neuron
- Rapid fire of the neurons may lead to their depletion
- The number or sensitivity of postsynaptic receptors may increase, depleting neurotransmitter levels
What breaks down biogenic amines?
MAO’s (monoamine oxidase)
What are 3 classifications of antidepressants?
- Tricyclic antidepressants (TCAs)
- MAO Inhibitors (MAOIs)
- Selective Serotonin Reuptake Inhibitors (SSRIs)
Which type of antidepressant is used most commonly and why?
SSRIs are most commonly used because of less adverse effects and they are much safer then the other antidepressants
What are the indications of use for antidepressants?
- Depression that persists at least 2 weeks, impairs social relationships or work performance, and occur are not associated with life events
- anxiety disorders
- enuresis (bedwetting)
- neuropathic pain (tricyclic antidepressants)
What do tricyclic antidepressants typically end in?
-ine
What drug typically ends in -ine?
tricyclic antidepressants
Which antidepressant is best for chronic pain?
tricyclic antidepressants
What is the prototype for tricyclic antidepressants?
Imipramine
What are some examples of MAOIs?
Isocaboxazid (Marplan)
Phenelzine (Nardil)
Tranylcypromine (Parnate)
What is Isocaboxazid (Marplan) used for?
Used for patients who did not respond to or could not take
newer, safer antidepressants
What is Phenelzine (Nardil) used for?
Used for some patients who did not respond to newer, safer
antidepressants
Whtaa is Tranylcypromine (Parnate) used for?
- Used for adult outpatients with reactive depression
What is the action of MAOIs?
Irreversibly inhibits MAO, allowing norepinephrine, serotonin, and dopamine to accumulate in the
synaptic cleft
What are the indications of MAOIs?
- treatment of patients with depression who are unresponsive to or unable to take other antidepressant agents
What are the contraindications and of MAOIs?
CONTRAINDICATION
- known allergy
- CV disease
- headaches
- renal or hepatic impairment
What are the adverse effects of MAOIs?
- Dizziness
- excitement
- nervousness
- mania
- hyperreflexia
- tremors
- confusion
- insomnia
- agitation
- liver toxicity
- nausea, vomiting, diarrhea or constipation
- anorexia
- weight gain
- dry mouth
- abdominal pain
What are the drug and food interactions of MAOIs?
- other antidepressants
- Methyldopa (sympathomimetic effects increase)
- Insulin or oral anti-diabetic medication
- Food interaction with Tyramine increase BP, can cause hypertensive crisis
What is tyramine amino acid in?
- Aged, mature cheeses (cheddar, blue, swiss)
- Smoked, pickled or aged meats, fish, poultry (herring, sausage, conrad beef salami, pepperoni, pate)
- Yeast extracts
- Red wines
- Italian broad beans (fava beans)
What is the prototype of MAOI inhibitors?
Phenelzine
What drug category is phynelzine?
MAOIs
What are selective serotonin reuptake inhibitors (SSRIs)?
- The newest group of antidepressant drugs
- Specifically block the reuptake of 5HT, with little to no
known effect on NE - Do not have the many adverse effects associated with TCAs and MAOIs
What are some examples of SSRIs?
- fluoxetine (Prozac)
- paroxetine (Pavix)
- sertraline (Zoloft)
- fluvoxamine (Luvox)
- citalopram (Celexa)
Which drugs end in -ine
SSRIs
What is the prototype for SSRIs?
fluoxetine (Prozac)
What is fluoxetine the prototype for?
SSRIs
What is the action of SSRI?
- INHIBITS CNS neuronal REUPTAKE of SERITONIN with little effect on norepinephrine and little affinity for cholinergic, histaminic, or alpha- adrenergic sites
What are SSRIs (fluoxetine) indicated for?
- Depression
- OCDs
- panic attacks
- bulimia
- PMDD
- post-traumatic stress disorders
- social phobias
- social anxiety disorders
What are the pharmacokinetics of SSRIs (fluoxetine)?
- Absorbed from the GI tract
- Metabolized in the liver
- Associated with congenital abnormalities
What are the contraindications of SSRIs(fluoxetine)?
- allergy
- pregnancy and laction
- impaired renal or hepatic function
What are the adverse reactions?
Headache, drowsiness, dizziness, insomnia, anxiety, tremor, agitation
**What are the drug interactions with fluoxetine?
- MAOIs
- TCAs increase of therapeutic and toxic effect
(other antidepressants)
How long does it take for SSRIs to be at there maximal effectiveness?
4-6 weeks
What is serotonin syndrome?
too much serotinin stimulation can lead to excessive nerve cell activity, causing a potentially deadly collection of symptoms known as serotonin syndrome
What are the symptoms of serotonin syndrome?
- Confusion
- Agitation or restlessness
- Dilated pupils
- Headache
- Changes in blood pressure and/or temperature
- Nausea and/or vomiting
- Diarrhea
- Rapid heart rate
- Tremor
- Loss of muscle coordination or twitching muscles
- Shivering and goose bumps
- Heavy sweating
What is discontinuation syndrome?
A withdrawal syndrome, also called a discontinuation syndrome is a set of symptoms occurring in discontinuation or dosage reduction of some types of medications.
How do you prevent discontinuation syndrome?
Slowly needs to be tapered down not abruptly stopped
What are some side effects of discontinuation syndrome?
Discontinuation syndrome results in:
- dizziness
- N&V
- Headaches
- anxiety
What assessment will the nurse make for patient on antidepressants?
- monitor for therapeutic effects by watching for cleanliness, hygeine, ADL’s (ask about work, how they are sleeping), watch for warning signs of suicide (most common in the start of therapy, may be heightened in adolescents
- important to check if they are pregnant
What is the most common complaint of SSRIs?
- most common complaints are weight gain and sexual disfunction
What are psychotherapeutic agents?
- drugs used to treat psychoses (help patients function in a more acceptable manner and carry on ADLs)
- used for children and adults
What is schizophrenia?
Characterized by hallucinations, paranoia, delusions, speech abnormalities, and
affective problems
What are the causes of schizophrenia?
- Strong genetic association
- May reflect a fundamental biochemical abnormality
What is mania?
Periods of extreme overactivity and
excitement
What is bipolar disorder?
Extremes of depression followed by hyperactivity and excitement
What is the cause of mania/bipolar disorder?
May reflect a biochemical imbalance followed by overcompensation on the part of neurons and their inability to re-establish stability
What are TYPICAL antipsychotics/neuroleptics?
- Primarily dopamine receptor blockers
- Cause several adverse effects including hypotension, anticholinergic effects, and extrapyramidal side effects (EPS)
- Chlorpromazine (Largactil), Haloperidol
What are ATYPICAL antipsychotics/neuroleptics?
- Block both dopamine receptors and serotonin receptors
- May alleviate some of the unpleasant neurological effects and depression of typical antipsychotics
- Clozapine (Clozaril), Risperidone (Risperdal), Olanzapine (Zyprexa)
What re antipsychotic adverse effects?
-Neuroleptic malignant syndrome (NMS)
and
-Extrapyramidal symptoms (EPS
What is neuroleptic malignant syndrome?
Potentially life threatening;
Symptoms include high fever, unstable blood pressure (BP), tachycardia, muscle rigidity
What are extrapyramidal symptoms (EPS)?
- pseudoparkinsonism (stiffness tremors, shuffling)
- dystonia (muscle spasms and torsion)
- Akathisea (motor restlessness, pacing, rockin, fidgeting)
- Tardive Dyskinesia (Hyperkinetic movement of the face, lips and tongue)
What is the treatment for EPS?
- Anti-parkinson anti-cholinergic drugs may be given
- benztropine (Cogentin)
What are some types of EPS?
- pseudoparkinsonism (stiffness tremors, shuffling)
- dystonia (muscle spasms and torsion)
- Akathisea (motor restlessness, pacing, rockin, fidgeting)
- Tardive Dyskinesia (Hyperkinetic movement of the face, lips and tongue)
What is the EPS called where you see stiffness shuffling and tremors?
pseudoparkinsonism
What is the EPS where you see muscle spasms and torsions?
dystonia
What is the EPS where you see motor restlessness, pacing, rocking and fidgeting?
akathisia
What is the EPS where you see hyperkinetic movement of the face, lips, and tongue?
tardive dyskinesia
Define pseudoparkinsonism.
EPS of stiffness, shuffling, tremors
Define dystonia.
muscle spasms & torsion (torticollis- involuntary head turning)
Define akathisia.
EPS with motor restlessness, pacing, rocking, fidgeting
Define tardive dyskinesia.
hyperkinetic movements of the face lips and tongue
What are the drug interactions of antipsychotics?
- ANTACIDS and TANNIC ACIDES (grapes, tea, wine) can decrease antipsychotic absorption
- ANTIHYPERTENSIVES may have addictive hypotensive effects
- CNS depressants may have additive CNS-depressant effect
- CLOZAPINE effects can be enhanced by GRAPE FRUIT (by reduced its metabolism) - reduced by NICOTINE (by speeding its metabolism)
What is the action of antipsychotic/neuroleptic drugs?
- typical antipsychotic drugs BLOCK DOPAMINE RECEPTORS, preventing the stimulation of the postsynaptic neurons by dopamine
- Depress the RAS, limiting the stimuli coming into the brain
- Atypical antipsychotic block both dopamine and serotinin receptors
What are the indications for antipsychotics/neuroleptic drugs?
- Schizophrenia
- Hyperactivity
- Combative behaviour
- Agitation in the elderly
- Severe behavioral problems in children
What are the pharmacokinetics of Antipsychotic/Neuroleptic drugs?
- Absorbed from GI tract
- IM dose provides four to five times the active dose as oral doses
- Widely distributed in the tissues
- Metabolized in the liver
- Excreted through bile and urine
- Cross placenta and enter breast milk
What are the adverse effects of Antipsychotic/Neuroleptic drugs?
- sedation
- weakness
- tremors
- drowsiness
- extrapyramidal effects
- dry mouth
- nasal congestions
- constipation
What are the contraindication for Antipsychotic/Neuroleptic drugs?
- underlying disease that could be exacerbated by dopamine-blocking effects of these drugs
- CNS depression
- Circulatory collapse
- Parkinsons disease
- Coronary disease
- Severe hypotension
- Prolonged QT interval
What are the drug interactions with Chlorpromazine?
- beta blockers
- alcohol
- mesoridazine
- thioridazine
What is the prototype of Antipsychotic/Neuroleptic drugs?
TYPICAL: chlorpromazine
ATYPICAL:
chlozapine
What type of drug is chlorpromazine?
TYPICAL Antipsychotic/Neuroleptic drugs
What routes can (typical antipsychotic) chlorpromazine be given?
Oral or IM
What is important to teach clients taking antipsychotic/neuroleptic drugs?
- adverse effects
- avoid alcohol, nicotine, or other drugs
- don’t stop taking meds because symptoms will return
- good to take it at night
- pink tinged urine can occur (not to worry)
Why is it important to teach the adverse effects of antipsychotic/neuroleptic drugs?
so the patient understands that the effects are from the drug, and its not them
What type of drug is chlozapine?
ATYPICAL antipsychotic
What routes can clozapine be given
PO
What drugs are used to treat Mania/Bipolar disease?
- Lithium salts (Cabolith, Lithane, Lithotabs)
- Lamotrigine (Lamictal)
- Olanzapine (Zypexa)
- Quetiapine (Seroquel)
What is the action of lithium?
- Alters sodium transport in nerve and muscle cells
- Inhibits the release of norepinephrine and dopamine, but not serotonin, from stimulated neurones
- Increases intraneuronal stores of norepinephrine and dopamine slightly
- Decreases intraneuronal content of second messengers
What are mood stabilizing agents?
- LITHIUM CARBONATE
- naturally occurring metallic salt
- used in the treatment of bipolar disorder
- totally excreted by kidneys
What are the therapeutic level of lithium carbonate?
- therapeutic levels 0.5-1.2 mEq/L
What are the toxic levels or lithium bicarbonate?
- toxic levels greater than 1.5 mEq/L
How often do people of lithium carbonate need to be monitored?
- monitor levels and sodium at least every 3m
What can toxicity of lithium bicarbonate cause?
Very narrow therapeutic window, and toxicity can cause multi organ failure and death
What are the pharmacokinetics of anti-manic drugs?
- Absorbed from GI tract
- Peak in 30 minutes
- Distribution pattern in the body as water
- Slowly crosses the blood- brain barrier.
- Excreted from the kidney, 80% is reabsorbed
- Crosses the placenta – associated with congenital abnormalities
- Enters the breast milk
What are the contraindications of Anti-manic drugs?
- known allergy
- renal & cardiac disease
- leukaemia
- metabolic disorders
- pregnancy & lactation
What are the drug interactions of anti manic drugs?
What are the adverse reactions of lithium serum levels?
Effects directly related to the lithium serum level
- Less than 1.5 – lethargy, slurred speech, muscle weakness, nausea, vomiting
- Levels 1.5-2 – above reactions plus ECG changes
- Levels 2-2.5 – ataxia, clonic movements, hyperreflexia, seizures
- Levels >2.5 Complex multiorgan toxicity, significant risk of death
What assessment would the nurse make for patient taking lithium?
- Start to monitor at about 8h and continue to monitor until you find an appropriate dose
- Once they go home
they need to have their lithium checked every 3m. - Teach about when to go to the hospital
- Dietary sodium remain about the same (too little causes too much lithium and too much causes too little lithium)
- Need to have lots of water (especially
in hot weather, etc) - Avoid caffeine however do not make big changes
